Clinical Documentation Typing
Clinical documentation has its own grammar: sections, shorthand, dosing strings, and a short list of abbreviations you must not use. Knowing the structure makes the typing faster, and the trainer's phrase corpus is built from it.
Note phrases, shorthand on Note phrases, spelled out Dosing strings only
Preset links open the trainer with those settings already applied; you can change them afterward.
The three notes you will type most
History and physical
The admission H&P is the longest note and the most vocabulary-dense. The history of present illness is prose, the review of systems and physical exam are lists of pertinent positives and negatives, and the assessment and plan is organized by problem. Typing bottlenecks are the exam findings (Conjunctivae pink w/o injection, Sensation intact to light touch and pinprick) and the medication list with doses.
Daily progress note
Usually SOAP or system-based. Interval events (No acute events overnight), vitals and labs (Tmax 38.2, BP 112/68, HR 96), a focused exam, and then a plan by problem or by system: cardiovascular, pulmonary, renal, gastrointestinal, infectious disease, endocrine, prophylaxis, disposition. These lines are short and formulaic, which is why shorthand dominates them.
Discharge summary
A hospital course narrative by problem, procedures and consults, condition at discharge, a reconciled medication list marked new, changed, stopped, or continued, pending results, follow-up appointments, and return precautions. It mixes full sentences with list items and is where most spelled-out drug names and doses in a chart live.
Shorthand reference
The abbreviation toggle in the trainer switches phrases between spelled-out and abbreviated forms using the conventions below. These are the ones that appear most often in the corpus.
| Shorthand | Meaning | Example |
|---|---|---|
| w/, w/o | with, without | Ambulating w/o assistance |
| s/p | status post | s/p laparoscopic cholecystectomy |
| c/f | concerning for | RLL consolidation c/f pneumonia |
| c/b | complicated by | Course c/b AKI |
| 2/2 | secondary to | Hyponatremia 2/2 SIADH |
| r/o | rule out | CT to r/o abscess |
| f/u | follow up | F/u w/ PCP in 1 week |
| Hx, PMH, FHx, SHx | history; past medical, family, social history | No family Hx of malignant hyperthermia |
| HD#, POD# | hospital day, postoperative day | POD#2, tolerating diet |
| NAD, A&Ox3, WNL, NKDA | no acute distress; alert and oriented x3; within normal limits; no known drug allergies | A&Ox3, NAD |
| PRN, q6h, BID, TID, qHS | as needed; every 6 hours; twice, three times daily; at bedtime | ketorolac 15 mg q6h PRN |
| NC, RA | nasal cannula, room air | SpO2 95% on 2L NC |
| 65-y/o | 65-year-old | 65-y/o w/ HFrEF |
Abbreviations you should not type
The Joint Commission maintains an official "do not use" list for patient-safety reasons, and most institutions enforce it in orders and notes. Write unit rather than U or u, international unit rather than IU, daily and every other day rather than QD or QOD, never use a trailing zero (5 mg, not 5.0 mg), always use a leading zero (0.5 mg, not .5 mg), and spell out morphine sulfate and magnesium sulfate rather than MS, MSO4, or MgSO4. The trainer's dosing strings follow these rules, so what you practice is what you should type.
Some abbreviations in the corpus, such as qd in older dosing strings, still appear in real charts even though many institutions discourage them. Follow your own institution's policy over any practice text.
Dosing strings
A dose is a drug name, a number, a unit, a route, and a frequency, in that order: lisinopril 20 mg po qd. Infusions add a rate unit: norepinephrine 0.08 mcg/kg/min. The trainer's dosing slider controls how often a drug name appears with a dosing string attached, from never to always. Setting it to 100 percent is the fastest way to get comfortable with units, slashes, and decimals.
For word-level drills on the terminology itself, see medical terminology typing. For how to structure sessions, see medical typing practice.